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Column: Nobody asked me, but …

February 4, 2014 - 19:52 -- Bart G.J. Knols
Malaria control is much more complicated and complex than can be highlighted within the confines of a few lines of text, but I need to share with you some of the things that make me wonder and keep me up some nights. I do not consider myself an alarmist, but as a public health entomologist there are a few things that concern me when I think of malaria control.

The World Malaria Report for 2013 paints an optimistic picture when it reports a fifty percent reduction in global mortality due malaria since 2000. However, the same report states that in 2012, “in 41 of the 103 countries reporting, which account for 80% of estimated cases, it is not possible to reliably assess malaria trends using the data submitted to WHO” as “information systems are weakest, and the challenges for strengthening systems are greatest, where the malaria burden is greatest.”...

Did I miss something? So what are simple field workers like me supposed to glean from these apparent contradictions? Are we winning or do we even know? Allow me a few observations from a simple-minded field entomologist.

Anyone who has spent any length of time working on malaria control in Africa or any other country knows that we have very a limited set of options we can deploy against malaria; and this is especially true when it comes to malaria vector control. Making matters interesting, insecticide resistance, particularly to Pyrethroids and DDT is a significant issue in many countries. (Mention the six magic letters, IRS & DDT, and things get really interesting.) As if that was not enough, there are reports that the pressure exerted on the vector from indoor residual spraying and mosquito net distribution in a good number of countries where these tools have been used has resulted in the vector modifying its behavior towards exophily and/or exophagy. 
Unlike decades ago, when the vector was attacked from several fronts, malaria control today is based mostly on mosquito nets. There is IRS conducted –mostly through the PMI-, but it is seldom done in conjunction with LLINs –or vice versa, for that matter; and larval source management (LSM) has just made a comeback. Moreover, most LLIN campaigns do not coordinate with their IRS or LSM counterparts in their countries -and vice versa. No one seems to be able to provide a good reason for this beyond attempting to justify it by blaming the restrictions set by the funding mechanisms involved. As a project manager, I am puzzled why malaria control continues to operate in a manner that doubles or triples the funding required for its implementation. Add LSM to the equation and we have at least three separate programs visiting essentially the same areas when they could be consolidated into a true, national malaria control program that operates year-round and provides a career path for the national staff and almost anyone else involved.
A handful of the “old timers” like myself wonder why is it that a joint meeting that would bring malaria control professionals from the World Health Organization (including WHO Pesticide Evaluation Scheme, Global Malaria Program, etc), the Global Fund, the PMI, the Bill and Melinda Gates Foundation, the World Bank Malaria Booster, the Clinton Foundation, the Carter Foundation, the Global Business Coalition for Health, and a handful of the dozens of NGOs and other agencies and organizations working on malaria under the same roof to discuss and coordinate malaria control has never happened. This gathering would result in a true, global malaria control program that would coordinate effort between agencies and deploy as many tools as possible against malaria –the disease and its vector- after adjusting them to fit local conditions as necessary. Unfortunately, bringing this idea for consideration during almost any international gathering on malaria generates a pretty consistent response from those who should be at least considering it: “Any money we spend on vector control is less money we can dedicate to mosquito nets.” 
I believe this attitude results in a monumental waste of money (tens of billions of US Dollars!) and resources and will only keep malaria active for years to come. Many taxpayers carrying the financial burden, many of whom have little knowledge of the impact of malaria on the populations it affects, let alone mosquito control are wondering why we, who should know better, let malaria control run this way. 
Malaria control needs to change. We should be hitting the disease and its vectors with everything we can deploy against them. We need to evaluate the methods used in other countries (currently and in the past) and see how/if they fit to Africa and other countries, change/modify/adjust them as necessary and deploy them as quickly as possible while keeping an eye on the disease and the vector and change/modify/adjust the specific country plans as needed. Doing anything less will only continue to keep the malaria yoke on the populations least able to alleviate its burden. 
It is a bit troubling and frustrating to me that we seem to have been doing essentially the same thing against malaria year after year during the past decade or so while continuing to expect different results each year. Wasn’t this was Albert Einstein’s definition of insanity?

Having said that, perhaps I am an alarmist! But I believe there are a handful of others working on malaria control who share my concerns.




Submitted by Graham Matthews (not verified) on

I was very interested to read Manuel’s column about the current situation regarding control of the mosquito vectors of malaria. I think the dominance of the Insecticide treated bednet is understandable as doctors wish to reduce the mortality of as many as possible. The bednet is ideal for young children most vulnerable to malaria and is “simple” to distribute to mothers if you forget that it has been difficult to distribute nets in some areas and without some teaching and nails the bednet may not be hung properly. Once the net gets torn, recent reports indicate finding mosquitoes inside LLITNs ! Generally medical entomologists have no training in using pesticides, so the main IRS programmes have been led by the PMI programme as Manuel has pointed out. He rightly points out that there is a lack of planning a comprehensive approach to vector control, that in individual countries needs support from people outside the Ministry of Health.
The first requirement is to recognise where the mosquitoes bred and determine whether there could be improvements in drainage within towns. Mapping areas with mosquito larvae that cannot be drained is a pre-requisite for optimising the use of larvicides. More difficult in rural areas but I have not seen even posters or other information getting to villagers to remind them to avoid water collecting near their houses. Others outside the Ministry of Health could help with getting houses improved by getting supplies of netting to screen houses into both urban and rural housing areas. The Ministry of Agriculture may be a source that can assist with getting IRS programmes operational at community level to avoid having to deploy ‘national teams’ that inevitably take a long time to cover vast areas.
In the USA, drainage and screening of doors was advocated on a large area-wide programme back in the 1930s and helped by using DDT, malaria was eliminated from the country. Today the nuisance mosquitoes and vectors of West Nile fever are controlled by a programme of larviciding and space treatments (Aerial and ground treatment) conducted by dedicated mosquito control teams in all the areas prone to mosquito infestations. In taking a fresh look at malaria control in sub-Saharan Africa it seems to me that governments need to set up special malaria vector control units, that can plan and co-ordinate the programme best suited to local requirements. This will be in part defined by the rainfall patterns as in some countries the key period for vector control is associated with the wet season. Our NGO the Yaounde Initiative Foundation In Cameroon failed in our attempt to encourage the government to set up a Sanaga river authority (similar to the Tennessee River Authority in the USA) failed to get the various Government departments to agree, although control of blackflies, is needed as they are a nuisance preventing development in areas near the river as well as being the vector of onchocerciasis.
That this approach could be very successful has already been shown by commercial companies that have adopted an integrated vector management programme to protect their workers. This has been illustrated by copper mines in Zambia and by Ashanti Gold in Ghana.

Submitted by Manuel Lluberas (not verified) on

Thanks for your note, Graham. It is unfortunate that, as public health entomologists, we face so many obstacles and arguments against deploying the few tools we have available. In the case of malaria, we continue to have to overcome the arguments Dr. Ross and Dr. Grassi faced a century ago: “Treat the disease, not the mosquito.” As public health entomologists, we understand that malaria and other vector-borne diseases are closely linked to the environmental factors you mentioned and to those we humans create. Unfortunately, as long as we keep treating malaria and the hundreds of arboviruses as communicable diseases, we will continue to have them affecting us. We need to consider vector-borne diseases as such, not as truly communicable one. After all, without the vector or a blood transfusion, there would be no transmission.